team power and synergy: project planning and...

39

FOUR

Team Power and Synergy: Project Planning and Program Management Essentials

■ Sandra E. Walters

■ Learning Objectives

1. Identify essential elements of effective

teams.

2. Identify and compare the stages of

team development.

3. Identify barriers to effectiveness in

interdisciplinary teams.

4. Identify multiple strategies for use in

managing work.

“Never doubt that a small group of thoughtful, committed citizens can change the world.”

—Margaret Mead

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CHAPTER FOUR Team Power and Synergy40

Key Terms Ad hoc committee Performing

Adjourning Program management

Brainstorming Project planning

Collaborating SBAR communication

Forming Storming

Interdisciplinary team Synergy

Multidisciplinary team Task force

Nominal grouping Team

Norming

Roles Advocate Integrator

Communicator Leader

Decision maker Risk anticipator

Professional Values Altruism Patient-centric care

Evidence-based practice Quality

Integrity Social justice

Core Competencies Appreciative inquiry Interpersonal infl uence

Assessment Leadership

Coordination Management

Critical thinking Resource management

Design Risk reduction

Emotional intelligence Systems thinking

Health promotion



Essential Elements of Teams 41

Introduction There are times when one single individual may possess the knowledge, skills, and

abilities to bring about changes in a healthcare system that result in the improve-

ment of care delivery. Singular skills are important, yet to get true buy-in, stake-

holder participation is critical. The implementation of any initiative from project planning and program management can be facilitated through the work of teams ,

and thus it is essential to understand how to maximize the effectiveness of using a

team approach.

Essential Elements of Teams The word team has evolved from the original Old English word, teme , which

indicated lineage, to a later term that referred to two or more animals harnessed

to a single vehicle, to its present-day use, which includes several persons asso-

ciated by work or activity (Merriam-Webster, 2010). Whether one is speaking

about football, baseball, corporations, departments, or offi ces, the word team

often implies that members of a group are all working toward a common goal

or purpose. An examination of the concept of teams in the healthcare literature

reveals the frequent use of the terms interdisciplinary and multidisciplinary in

referring to the composition of the teams. Careful examination shows these terms

are often used interchangeably, although there is a difference and the distinction

is important.

One widely used defi nition of interdisciplinary team was put forth by Drinka

and Clark (2000), who defi ned it as individuals working together in a group to solve

problems too complex to be addressed by one discipline or multiple disciplines

acting in sequence. Inherent in this defi nition of the interdisciplinary team is that

individuals have diversity in training and in their backgrounds, and that they come

together collaboratively in formal or informal structures. The use of individuals

who come together from different disciplines allows the team to capitalize on the

variations in the approach to problems, provides opportunities for learning about

overlapping roles, and accounts for power differences within the organization while

establishing the goals and mission of the team.

Similarly, a multidisciplinary team also includes professionals from a range

of disciplines working together to solve a problem such as would be presented




by the complex healthcare needs of a patient with multiple medical issues

(Von Gunten, Ferris, Portenoy, & Glajchen, 2001). Underlying the concept of the

multidisciplinary team is that each discipline performs its functions in a sequential

manner rather than as a member of an interacting and collaborating group, and

the goals of each discipline may be established separately from those of the other

members of the group (Mitchell, Tieman, & Shelby-James, 2008).

To illustrate the difference between an interdisciplinary team and multidisciplinary

team, it is useful to examine the fi ctional case of patient Imogene Withers ( Box 4-1 ).

Mrs. Imogene Withers is an 82-year-old widow admitted to her local hospital following a fall at the local grocery store. On admission, she was found to have a hip fracture and low serum glucose and was noted to live alone. After her hip-replacement surgery, a multidisciplinary discharge planning confer-ence was held on the unit to discuss the patient’s potential for discharge. The nurse, surgeon, an internal medicine doctor, physical therapist, social worker, dietitian, and occupational therapist were in attendance. When discussing Mrs. Withers, the surgeon indicated the fracture was healing slowly and he was concerned regarding the patient’s ability to ambulate. The physical therapist and occupational therapist reported each had been treating the patient and concurred that her progress had been slower than expected and that she would require more extensive rehabilitation. The dietitian indicated she could evaluate the patient’s nutritional status to determine if she had suffi cient nutrients to promote healing. The medical doctor indicated Mrs. Withers’s hypoglycemia had been attributed to a lack of nutritional intake but that subsequent laboratory tests were within normal limits and no further follow-up for this was needed. The team made the decision to place Ms. Withers in a rehabilitation unit until suffi cient progress was made to discharge the patient to her home. Each member of the mul-tidisciplinary team documented his or her recommendations for follow-up care in the patient record.

Mrs. Withers’s transfer to the rehabilitation unit was completed and was followed by a request from her nurse to assemble an interdisciplinary team to establish the goals of her care. In addition to Mrs. Withers, the nurse, an internal medicine doctor, a physical therapist, a social worker, a dietitian, and an occupational therapist were in attendance. Following discussion with Mrs. Withers, it was determined that the team would seek to maximize Mrs. Withers’s quality of life and safety. The social worker agreed to explore

Box 4-1 Case Study



Stages in Team Development 43

Upon review of the case presented on the care of Mrs. Withers, it should be

noted that the multidisciplinary approach presents the work of several disciplines

with each focusing on its goals for the patient. By contrast, the interdisciplinary

approach brings together multiple disciplines, but the goal is one common goal for

all disciplines, with everyone assuming complementary roles and working together

toward the same ends. In effect, each discipline loses its separate identity and its

goals become those of the team (Von Gunten et al., 2001).

Applying concepts of team energy to project management, this seamless

approach underscores the need for continuity and fl ow. In addition to interdisci-

plinary and multidisciplinary teams, other types of groups that can be formed for

problem-solving initiatives are those of task forces and ad hoc committees . Task

forces are groups of individuals who come together for the purpose of completing

a given assignment or goal within defi ned time limits. In similar manner, an ad hoc

committee is one formed temporarily to address a specifi c issue within a specifi c time

frame but is additionally created from a larger grouping or committee (American

Heritage Dictionary, 2009). Because of the complexity of the healthcare system, it

is assumed that task forces and ad hoc committees will be comprised of individuals

from a variety of disciplines, and thus the task forces and ad hoc committees will

possess characteristics similar to those of the interdisciplinary teams.

Stages in Team Development One of the advantages of teams has been identifi ed as providing staff from mul-

tiple departments opportunities to resolve operational issues by bringing their

options for Mrs. Withers’s living arrangements once she went home and she arranged to meet with the therapists to determine how to address Mrs. Withers’s limitations for living alone. Additionally, the team determined pain and fatigue were deterring Mrs. Withers from participating fully in her therapy, and thus plans were made to provide pain medication prior to therapy and to allow suffi cient rest periods between activities. Subsequently, each member of the team determined how he or she could contribute to enhancing Mrs. Withers’s quality of life and while addressing her safety requirements. When all the plans were fi nalized, the nurse documented the interdisciplinary team member proceedings including the plan of care, expected outcomes, and follow-up plans.




knowledge of what needs to be fi xed together with a mechanism to collaborate

and take actions (Studer, 2003). This advantage is believed to be the result of

synergy , which is the phenomenon that occurs when the whole is greater than the

sum of its parts as happens with teamwork (Sholtes, 2010). Whether the teams are

composed of multiple professionals functioning as a team within one organiza-

tion or of professionals from multiple organizations, the development of the team

is believed to undergo similar stages during the course of work. Four stages of

team synergy were identifi ed by Bruce Tuckman in 1965 as including forming ,

storming , norming , and performing , with a fi fth stage, adjourning, identifi ed

in 1977 (Tuckman, 2001).

During forming, the team is assembled, and each member is initially focused on

his/her own objectives. Orientation to the tasks or team goals takes place during this

phase, and team members often engage in behaviors that test the group dynamics

(Tuckman, 2001). Team members’ emotional response may vary widely from pride

in their selection for the team to apprehension regarding the work ahead (Sholtes,

2010). As the orientation is completed and the tasks and requirements become evi-

dent, resistance to the group infl uence emerges and intragroup confl ict may arise,

which indicates the team is storming (Tuckman, 2001). During this stage, team

members have low levels of trust and often display anger and resentment. While turf

battles may ensue, the foundations for trust and respect may be developed during

this stage based on how confl icts are resolved. During the norming phase that fol-

lows, group cohesiveness develops, and members adjust to their roles in the team

(Tuckman, 2001). Open communication during this phase facilitates constructive

discussions and the sharing of personal insights (Sholtes, 2010). As the team mem-

bers bind together around their common goals, the work phase of the team begins

and productivity increases rapidly during the performing stage (Tuckman, 2001).

Team synergy becomes evident as member roles become fl exible and the focus shifts

to the tasks at hand. Members will display team loyalty, will be able to capitalize

on individual strengths, and will support team efforts. As tasks are completed and

the outcomes of the work lead to self-evaluation by the team and its members, the

adjourning phase is reached and may lead to sadness and mourning as members face

the completion of the goals and group tasks (Tuckman, 2001). A summary of Tuck-

man’s stages of team development is presented in Table 4-1 .

It should be noted that while Tuckman’s model suggests a linear relationship

among the phases of team synergy formation, the stages may not occur sequentially



Barriers to Effectiveness in Interdisciplinary Teams 45

and may be repeated or interrupted at any point in time. Unexpected occurrences, such

as the introduction of a new team member, may disrupt established team dynamics

and may shift the team to either an earlier or later stage (Tuckman, 2001).

Barriers to Effectiveness in Interdisciplinary Teams Progression through the stages of team development as identifi ed by Tuckman

requires that the team achieve effi ciency at each stage. Lencioni (2002) identifi ed

barriers to effectiveness at each stage that undermine the effectiveness of teams

and cause them to fail in their endeavors. Problems he identifi ed among team

members included an inability to trust or have reliance on others, fear of confl ict,

lack of commitment, having low standards such that accountability is avoided,

and inattention to the results of the team and instead a focus on individual

achievement.

Table 4-1 Tuckman’s Stages of Team Development

Stage Member Dynamics Task Orientation

1. Forming Members focus on their goals

Group dynamics are tested

Pride or apprehension evident

Team established

Orientation of team members

2. Storming Resistance to group goals

Confl icts often evident

Trust in group is low

Emotional response to tasks

Turf wars possible

3. Norming Trust is established

Open communication allowed

Ideas shared and accepted

Role adjustment occurs

4. Performing Team loyalty evident

Use of member strengths

Positive attitudes evident

Greatest productivity

Focus is on tasks and goals

5. Adjourning Evaluation of outcomes

Sadness or mourning may begin as tasks are completed

Team dissolved or transformed




Addressing each of the barriers identifi ed by Lencioni (2002) is possible

through effective leadership. To begin with, the responsibility of a program

planner or project manager is to assist team members in developing trust by

demonstrating reliance on the team as a means of overcoming the limitation in

the knowledge, skills, or abilities of any individual team members. One means

to achieve this is through a willingness to demonstrate vulnerability. The second

limitation, that of fearing confl ict, requires that team leaders support constructive

debates and demonstrate the ability to manage it by establishing group norms for

dealing with issues in a manner that is respectful of all team members. With a lack

of commitment, the underlying problem is a lack of decision-making capacity by

the team such that individuals seek consensus instead of achieving a clear position

on issues. This can be resolved through inclusion of all points of view in making

decisions. Similarly, a lack of accountability can be countered by assisting the

team to focus on goals, continually tracking team progress, and communicating

frequently with the team through meetings and status reports. Finally, inattention

to the results of the team can be minimized through the selection of measures

that clearly defi ne success for the team effort and the development of a tracking

mechanism to monitor team progress. Success and failures must be equally shared

within the team and used to reinforce progress to goals.

In addition to the barriers identifi ed by Lencioni (2002), Atwal and Caldwell

(2006) conducted a study of nurses’ perception regarding multidisciplinary team-

work and identifi ed barriers that hinder teamwork as including the following:

■ Different perceptions of teamwork are held by nurses compared with other

members of the team.

■ A difference in the level of skills required for team members to function

within teams is often present.

■ Disciplines lack equal power within teams with medical power being

dominant.

Their fi ndings suggest that educators and nursing managers should focus on

developing staff member abilities to function within teams, and the team skills must

include an understanding of the nurse’s role as well as those of other disciplines.

Multiple barriers to effi cient team functioning in healthcare settings have

been identifi ed and are often presented as communication obstacles that are listed

in Box 4-2 (Agency for Healthcare Research and Quality, 2008; O’Daniel &

Rosenstein, 2008).



Strategies for Work Management 47

Strategies for Work Management The use of standardized communication tools to support teamwork in complexity

of the healthcare environment has been explored in the literature as a means of

improving decision making and increasing safety (O’Daniel & Rosenstein, 2008).

Strategies include the use of techniques such as brainstorming , nominal grouping ,

and SBAR communication .

Brainstorming sessions are used to generate a large number of ideas through

interaction among team members. In this strategy, the objective of the brainstorming

is established and is often directly related to the team goals. One individual is selected

to record ideas (generally on a board or fl ip chart) to avoid duplications. Individuals

in the group then call out ideas in turn with the process continuing until no further

ideas emerge. The essential rules of brainstorming are that everyone participates and

that no discussion, critique, or evaluation of the ideas takes place during the session.

Following the creative thinking session, each is clarifi ed to facilitate subsequent

discussion of its feasibility.

The development of cooperative agendas can ameliorate the impact of

communication barriers and can be facilitated by the fact that healthcare team mem-

bers generally share the value of meeting the needs of patients or clients (O’Daniel &

Rosenstein, 2008).

Gender differences Distraction (cellular phones, pagers) Fatigue Excessive workload Time constraints Hierarchical relationships Information silos Differences in accountability, compensation, and rewards Cultural and ethnic differences Historical professional rivalries Language and terminology differences Disruptive behaviors, aggression

Box 4-2 Communication Obstacles to Team Effectiveness




In similar manner, the nominal group process begins with the establishment of

an objective but proceeds with each member generating his or her own list of pos-

sible solutions. When suffi cient time has been allowed, members take turns calling

out their ideas to the group. As with the brainstorming session, ideas are not dis-

cussed until all have been presented. Once the list of ideas is complete, clarifi cation

follows as with the brainstorming session.

Once ideas are generated using brainstorming or nominal group processes,

the team proceeds to decrease the list by such mechanisms as voting to eliminate

ideas that are not feasible, identifying items that may be readily implemented (low-

hanging fruit), and rank ordering related alternatives. Rank ordering can be accom-

plished by having individual team members rank each idea and then calculating

average scores for each idea to determine the degree of agreement amongst team

members. Clarifi cation and discussion of the strengths, weaknesses, opportuni-

ties, and threats of each idea can be undertaken by the team and is referred to as

a SWOT analysis. Additionally, an affi nity diagram, in which ideas are written on

cards and placed randomly on a table or chart, can be generated. Like or related

ideas are then placed together by group members working silently. When cards are

no longer being moved, the group then discusses the ideas and generates a title for

each group. Each method is useful in exploring alternative plans of action towards

goal attainment.

An additional strategy, that of SBAR communication, was developed at Kaiser

Permanente and is among the techniques useful in teamwork for communicating

essential information using a standardized format. In this strategy, communication is

provided using the format of s ituation, b ackground, a ssessment, and r ecommenda-

tion (SBAR). To begin with, the situation is outlined using a brief summary of what is

going on. This is followed by background information about the clinical situation or

the context of the issue. The assessment component presents a statement of what the

individual has identifi ed as the problem and is followed by a recommendation of

what corrective action is needed. Originally developed to facilitate communica-

tion between nurses and physicians, the use of a standardized format within team

communication dynamics provides a succinct method of communicating information

rapidly.

The work of a team to improve processes can be both challenging and rewarding.

Effective leadership is facilitated through the use of structures and tools to ensure

participation by all members of the team.



Learning Activities 49

Summary ■ Implementation of any initiative from project planning and program

management can be facilitated through the work of teams.

■ Five stages of team synergy are forming, storming, norming, performing, and

adjourning.

■ Problems in team development include inability to trust, fear of confl ict, lack

of commitment, low standards, and inattention to results.

■ Multiple strategies may be used to increase the effectiveness of teamwork and

include the use of brainstorming, nominal group processes, affi nity diagrams,

SWOT analyses, and the use of SBAR communication techniques.

Refl ection Questions 1. During a period of prolonged emergency leave by the chairperson of the

patient safety committee, hospital administrators have requested you assume

responsibility for decreasing the number of patient falls in the rehabilitation

unit. Upon arriving at the meeting of the patient falls committee, you note

members of the rehabilitation medicine teams are sitting together apart from

the rest of the group. As the meeting begins, you note they are whispering to

each other and are not contributing to the discussions.

Identify the stage of team development. Identify multiple strategies

to use in moving the group forward in achieving the goals of reducing

patient falls.

2. The medical unit at a local hospital has identifi ed the need to convene an

interdisciplinary team to facilitate intrafacility transfers. Identify what disci-

plines you would include in the team. Determine what communication norms

would be useful to enhance the work of the team.

Learning Activities 1. Identify what committees, teams, or task forces are in place at your local

healthcare facility. Attend their meetings and use Tuckman’s model to

determine what stage of development each team is in.




2. Analyze communication strategies in use during a departmental meeting.

Compare this to the communication strategies in use during an interdisci-

plinary team meeting. What similarities or differences exist? Identify effective

strategies in use, potential barriers to communication, and mechanisms for

their elimination.

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American Heritage Dictionary of the English Language (4th ed.). (2009). New York: Houghton

Miffl in Company.

Atwal, A., & Caldwell, C. (2006). Nurses’ perceptions of multidisciplinary team work in acute

health-care. International Journal of Nursing Practice, 12 (6) , 359–365.

Drinka, T. J. K., & Clark, P. G. (2000). Health care teamwork: Interdisciplinary practice & teaching. Westport, CT: Greenwood Publishing Group.

Lencioni, P. M. (2002). The fi ve dysfunctions of a team: A leadership fable. San Francisco:

Jossey-Bass.

Merriam-Webster. (2010). Team. In Merriam-Webster online dictionary. Retrieved from

http://www.merriam-webster.com/dictionary/team

Mitchell, G. K., Tieman, J. J., & Shelby-James, T. M. (2008). Multidisciplinary care planning and

teamwork in primary care. Medical Journal of Australia, 188 (8) , 63.

O’Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team collaboration.

In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses

(Vol. 2). Rockville, MD: Agency for Healthcare Research and Quality.

Sholtes, P. R. (2010). Team dynamics. Retrieved from http://www.cls.utk.edu/pdf/ls/Week3

_Lesson17.pdf

Studer, Q. (2003). Hardwiring excellence: Purpose, worthwhile work, making a difference.

Gulf Breeze, FL: Fire Starter Publishing.

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Von Gunten, C. F., Ferris F. D., Portenoy, R. K., & Glajchen, M. (Eds.). (2001). CAPC manual: How to establish a palliative care program. New York: Center to Advance Palliative Care.



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